Why your workers’ comp claim was denied

Theoretically, workers’ compensation aims to provide injured workers with a fast, uncomplicated way to get the health benefits they need. In practice, some applicants encounter roadblocks during this process.

If you receive a notice that your claim was controverted (denied), the denial can stem from a mistake you made or from the insurer’s disagreement on fundamental issues. You may be able to appeal this decision; consult your lawyer as to your chances of success on appeal.

Your job is not covered by workers comp

Some denials arrive because you belong to a class of workers to whom workers’ comp coverage does not extend. This can be the case if you are a contract taxi driver, a non-commercial cleaner, a sole business owner or a nonprofit organization officer. Part-time and temporary workers also do not get workers’ comp benefits.

The insurer says your injury has no connection with your job

Sometimes, the insurance company decides that your injury did not occur in the course of your job or on company property. Disputes in this area can arise when the job involves going off company property or when the worker is on company property outside of business hours. Further, injuries stemming from deliberate horseplay or intoxication may not be covered, while injuries that happen due to mere carelessness should be. When pursuing an appeal, you may need to present more comprehensive evidence as to the circumstances of the injury.

The insurer claims your injury does not warrant benefits

In other cases, the insurer may agree that you sustained an injury at work but may claim you do not need any further treatment or that your injury will not prevent you from earning your normal wage. This can happen when they conduct an independent medical examination and the physician disagrees with your own doctors’ opinion. To fight this type of situation, you need solid medical evidence to back up your doctor’s conclusions. You may need to see additional specialists. It is also vital that you comply with your healthcare team’s instructions, keep appointments and take the medications they prescribe.